Physiotherapy in the treatment of neck and shoulder pain

Physiotherapy in the treatment of neck and shoulder pain =================================== Considering the variety of causes and severity of pain, each patient's treatment plan is adjusted according to his individual needs and goals in order to achieve the best results. In this blog, comprehensively and based on the latest scientific evidence, we will examine the different stages of physiotherapy in the treatment of neck and shoulder pain; From accurate clinical evaluation and diagnosis of the main causes of pain to the introduction of stretching and strengthening exercises, manual therapy techniques and proper ergonomic correction tips. By following these guidelines and performing the exercises correctly, you can take an effective step toward reducing pain, improving performance, and returning to your active life. In the process of physiotherapy treatment, the simultaneous use of passive methods such as modules and physical devices and active physical exercises increases the range of motion, strengthens the supporting muscles and improves the stability of the joints. Studies have shown that specific exercises such as arm circular movements, trapezius muscle stretching, and deep neck strengthening exercises can greatly reduce pain symptoms and prevent recurrence of problems. In addition, manual therapy including joint mobilization and soft tissue massage plays an important role in speeding up the healing process by improving blood circulation and reducing muscle tension. ** Causes of neck and shoulder pain ** Neck and shoulder pain can be caused by a combination of different factors, including incorrect body posture, muscle tension, degenerative changes in the bone and disc structure, as well as less common but serious causes. These factors can be classified into four general categories: postural disorders, muscle tension and injuries, structural disorders, and other reasons related to nerves or systemic conditions. In the following, each of these categories will be examined in more detail to fully clarify the role of each factor in creating and aggravating neck and shoulder pain. ### **1. Postural disorders** - Improper posture caused by long-term sitting in front of the computer or mobile phone causes chronic muscle strain and pressure on the cervical vertebrae. - The error in adjusting the height of the table and chair and the inappropriate distance between the eyes and the screen also puts extra pressure on the shoulders and neck and eventually leads to chronic pain. - Incorrect sleeping habits, such as using too long or too short pillows, cause the wrong angle of the neck during sleep and lead to pain and cramps in the morning. - Standing disproportionately and bending the shoulders in daily activities can also cause long-term damage to joints and ligaments. ### 2. **muscle tension and injuries** - Repetitive activities such as carrying heavy loads or strenuous sports can cause stretching and fatigue of neck and shoulder muscles. - Trigger points or trigger points in the trapezius and sternum muscles may cause referred pain to the neck and shoulder with repeated muscle tension. - Sudden muscle spasms can also lead to severe pain and temporary limitation of movement. - Shock or direct impact to the neck and shoulder area, such as a car accident, can lead to damage to ligaments, muscles and intervertebral discs. ### 3. **structural disorders** - Degenerative disease of the intervertebral discs in the neck (Cervical Degenerative Disc Disease) causes a decrease in the height of the disc and more load on the facet joints. - Osteoarthritis or arthrosis of the facet joints may narrow the space around the spinal cord and nerves with the formation of bone spurs and cause numbness and pain spreading to the shoulder. - Cervical disc herniation occurs when the internal gelatinous substance of the disc comes out through the fibrotic ring and puts pressure on the nerve roots, which can cause sharp and widespread pain in the shoulder and arm. Tumors of the cervical spine, although rarely, may cause chronic neck and shoulder pain by pressing on nerve or vascular tissues. ### **other causes** - Compressed nerves in the neck area, such as cervical radiculopathy, radiate pain and shooting to the shoulder and sometimes to the hands. - Inflammatory factors such as shoulder bursitis and rotator cuff tendinopathy can cause local pain and limitation of movement of the shoulder. - Systemic conditions such as rheumatoid arthritis and polymyalgia rheumatica can also cause pain in both neck and shoulder areas. - In very rare cases, shoulder pain may be due to internal referral diseases such as heart problems (heart attack), gall bladder problems or cancer, which requires careful medical examination. Prevention of neck and shoulder pain Prevention of neck and shoulder pain requires the use of multifaceted strategies, including improving the ergonomics of the work and living environment, regular exercise program and changing daily behaviors. By adopting these measures, 70-80% of symptoms can be prevented and the quality of life can be improved. **Ergonomic correction** - Suitable table and chair: the height of the chair should be adjusted so that the feet are completely on the floor and the knees are at an angle of about 90 degrees. The back of the chair should support the natural arch of the back. Screen adjustment: The screen should be exactly at eye level or a little lower to prevent excessive bending of the neck and compression of the back muscles. - Peripheral tools: using an ergonomic keyboard and mouse, a footrest if needed, and a mobile phone or tablet holder can reduce extra pressure on the neck and shoulder muscles. **Active breaks and behavior change** - Regular breaks: Get up every 30-45 minutes, do simple stretches and correct your posture. This increases blood circulation and prevents muscle cramps. - Adjustment of daily activities: when lifting heavy objects, bend the knees and instead of bending the neck, use the leg muscles to remove the pressure from the cervical vertebrae. **regular exercise program** - Preventive exercises: A combined exercise program of light aerobic exercises (walking, swimming), strengthening exercises and flexibility exercises can reduce the risk of neck pain by 51%. - Gentle strengthening exercises: strengthening the deep muscles of the neck and shoulder stabilizers (such as isometric exercises of the neck and gathering the shoulder blade) prevents muscle imbalance and future injuries. **Intervention in the work environment** - Occupational assessment: Companies and organizations should modify work tools and processes by performing an ergonomic risk assessment to reduce pain-inducing factors. - Training employees: training the principles of correct posture and safe use of equipment, along with continuous monitoring of the work environment, can significantly reduce the prevalence of musculoskeletal disorders. The role of physiotherapy in the treatment of neck and shoulder pain ### **Individual examination and planning** in the treatment of neck and shoulder pain In the first stage, the physiotherapist uses comprehensive evaluations including measuring the range of motion of the neck and shoulder joints, resistance muscle strength tests, and examining the patient's pain pattern to accurately identify the underlying causes of pain. These evaluations are usually performed with a combination of tools such as a goniometer to measure the angle of movement, a dynamometer to measure force, and special neurological tests to determine the relationship between neurological and muscular disorders. Then, taking into account the patient's medical records, including the presence of disc herniation or facet joint arthrosis, the physiotherapist defines short-term and long-term treatment goals and formulates a personalized plan. In addition, it is determined which part of the treatment has the highest priority; For example, reducing inflammation, restoring the range of motion or strengthening the supporting structures of the joint. The obtained information is also used in monitoring the therapeutic changes so that the methods used during the next sessions can be modified and optimized. In cases where the patient's pain is caused by trigger points or chronic muscle tension, the physiotherapist may also include direct pressure tests and massage of soft structures to determine the exact location and extent of these muscle knots. Finally, the treatment plan includes a specific time sequence for re-evaluating the patient, changing the intensity or type of exercises and determining the progress criteria so that the physiotherapist and the patient can follow the improvement process well. This regular and continuous process provides a solid foundation for achieving optimal treatment results and lasting reduction of neck and shoulder pain symptoms. ### **Manual treatment techniques** in the treatment of neck and shoulder pain Manual physiotherapy treatment includes joint mobilization methods and soft tissue massage, which are performed with the aim of increasing joint slipperiness, reducing adhesion and muscle tension. Joint mobilization is done in the form of slow and controlled movements in the limited ranges of the joints to reduce the internal pressure of the joint and improve the synovial fluid, which leads to ease of movement and pain reduction. In addition, soft tissue massage by manipulating the deep layers of muscles and fascia increases local blood circulation and improves the tissue repair process. Massage techniques include trigger points, ischemic pressure, and longitudinal rubbing, each of which helps reduce muscle tone and increase muscle flexibility. In some cases, the physiotherapist uses additional methods such as transcutaneous electrical nerve stimulation (TENS) or ultrasound to increase the effect of manual therapy to help reduce inflammation and accelerate tissue healing. Studies have shown that the combination of these methods with active exercises is more effective in improving the pain faster and better functioning of the joints than using them alone. Also, manual therapy can help to improve proprioception in the neck and shoulder joints and thus increase muscle balance and coordination. In general, manual therapy techniques play a key role in immediate pain relief and providing a suitable basis for continuing active physical exercises so that patients gradually regain motor independence and normal function. ### **Ergonomic correction and patient education** in the treatment of neck and shoulder pain Improving the ergonomics of the work environment and daily activities is one of the important pillars of physiotherapy in managing neck and shoulder pain, and it includes adjusting the height of the desk and monitor, the proper distance between the eyes and the screen, and the use of supportive chairs with adjustable backs. According to clinical guidelines, it is recommended to place the monitor at eye level and use a standing table or height-adjustable table in order to reduce chronic pressure on the trapezius and trapezius muscles. Also, teaching active breaks during the day to perform short-term stretching exercises every 30-45 minutes increases the local blood flow in the neck and shoulder muscles and prevents stiffness and cramps. Physiotherapist can prevent morning pain and cramping by teaching the right tips for sleeping, including choosing the right pillow and maintaining the natural curvature of the neck while lying down. Providing guidance on correct sitting position by maintaining the natural back curve, standard distance between the elbows and the table and keeping the shoulders in a neutral position also helps to reduce moderate to severe tensions. Along with improving ergonomics, self-care training including deep breathing techniques, basic self-massage and stress management methods play an important role in reducing inflammatory reactions and pain sensitivity. At the end of the treatment process, it is expected that the patient will find the ability to identify and correct high-risk situations in the work environment and personal life and continue with more confident exercises and ergonomic recommendations to prevent the return of pain. ### Stretching and strengthening exercises in the treatment of neck and shoulder pain Active exercises in physical therapy for the neck and shoulder include a combination of stretching exercises to increase flexibility and strengthening exercises to improve joint stability. **Specialized stretches such as upper trapezius stretch, isometric endurance stretch, and corner wall stretch help reduce chronic tension in the trapezius and pectoral muscles, and the movements are held in a controlled manner for 20-30 seconds to improve the response of the connective tissue.** Strengthening exercises such as chin-ups, resistance exercises with elastics inspired by deep neck stabilization techniques, and shoulder blade adduction exercises are designed to activate the scapular levator and deductor muscles to improve muscle coordination and balance. It is recommended that these exercises be done gradually with a gradual increase in the resistance load or the number of repetitions to prevent premature fatigue or mechanical damage. **For patients with chronic neck pain, combined exercise protocols including low-pressure aerobic exercises such as walking or swimming along with resistance exercises for the deep muscles of the neck have shown better results than single exercises.** The important role of strengthening exercises in restoring the stability of the neck and shoulder joints and preventing the recurrence of pain has been emphasized, especially in working people and athletes. In the first sessions, the exercises should be done under the direct supervision of the physiotherapist to ensure the correct technique and controlled muscle tension, and in the later stages, the program can be transferred to the home to maintain the continuity of the treatment. Finally, the regular combination of these exercises with continuous monitoring of the patient's progress is the key to success in achieving long-term improvement and reducing dependence on pain medication. #### **stretching exercises** for neck and shoulder **1. Chin Tuck** - Sit or stand and keep the spine straight. - Gently press the chin inward (toward the neck) to feel a stretch in the back of the neck. Hold this position for 15 to 30 seconds and then release slowly. - Repeat the movement 8-10 times and do it 2-3 times a day. **2. Side Neck Stretch** - Keep your spine straight while standing or sitting. - Tilt the head slowly to the right until the right ear is close to the shoulder, without raising the shoulder. - With the right hand, apply a little gentle pressure downwards to increase the tension. - Hold for 15-30 seconds, then repeat for the left side. **3. Upper Trapezius Stretch** - Sit in a sitting position with a straight back. - Bend the head to the right side and press the head towards the shoulder with the right hand. Stay in the same position and then slowly return to the starting position. - Repeat the movement 3-5 times for each side. **4. Cross-Body Shoulder Stretch** - In a standing or sitting position, place the right hand in front of the chest. - With the left hand, hold the right hand near the elbow and slowly pull it towards the chest. - Hold for 15-30 seconds and then repeat for the opposite side. - Do this movement 2-4 times for each arm. **5. Corner Pec Stretch ** - Stand facing the corner of the wall and place both forearms on the wall at shoulder height. - Slowly move the trunk forward to feel the tension in the chest and shoulders. - Hold for 20-30 seconds, then rest. - Continue for 2-3 repetitions. #### Strengthening exercises for the neck and shoulders **1. Isometric strengthening of the neck (Neck Isometrics)** - Sit on a chair, back straight and body weight balanced on the seat. - Place the palm on the forehead and resist with the neck, press for 10 seconds and then release. - Repeat the same thing by pressing on the sides of the head and the back of the head (5 repetitions on each side). **2. Shoulder Blade Squeeze** - Stand or sit, arms hanging by the body. - Take the shoulders back and bring the shoulder blades together, hold for 5-10 seconds. - Then relax and repeat 10-15 times. **3. Deep Neck Flexor Activation** - Stand facing the mirror so that you can check the condition of the neck. - Move the chin inward slowly (similar to chin tuck) and without bending the neck, slightly guide the head down. - Hold for 5 seconds, then release and repeat 10-15 times. **4. Shoulder Shrug ** - Stand up, feet slightly apart, hands next to the body. - Raise the shoulders towards the ears, hold for 3-5 seconds, then lower slowly. - Do this movement 10-12 times. **5. Resisted Neck Rotation** - Sit on a chair, place the right hand behind the head and near the left temple. - Turn your neck slowly to the right and keep your hand for 10 seconds. - Do 5 repetitions for each side. By regularly repeating these exercises and implementing the correct technique, you can experience a significant reduction in pain and improvement in the range of motion of the neck and shoulder after a few weeks. Neck and shoulder pain at different ages The prevalence of neck and shoulder pain varies in different age groups and is affected by physiological factors, lifestyle and work load. In children and adolescents, studies have shown that between **6%** (12-year-olds) and **45%** (18-year-olds) suffer from neck or shoulder pain. In adults, the six-month prevalence has been reported between **6.9%** and **54.2%** with an average of around **29.8%**. In the elderly aged 70-79, **11.9%** complain of neck pain and **18.9%** complain of shoulder pain, and the prevalence of shoulder pain increases with age, especially after the age of 50. ### **Neck and shoulder pain in children and teenagers** - **prevalence and combination of pains:** In a study on 525 teenage students, **43%** of them suffered from shoulder pain and **36-32%** from neck pain. About **15.9%** had pain in two areas and **6.8%** had pain in three areas at the same time. - **Sports and activity risk factors:** Adolescent athletes, especially in handball and judo (15-19 years old), have up to **43.5%** probability of shoulder pain; which affects rotational skills and repetitive loading of the shoulder. - **Intensification in the growth pattern:** As the age of 12-18 years passes, the percentage of pain increases (6% in 12-year-olds to 45% in 18-year-old girls) due to the rapid growth of the skeleton, hormonal changes and increased daily activities. - **Psycho-social consequences:** A study in Norway showed that **20%** of teenagers have neck/shoulder pain in addition to mental problems (such as depression) and chronic headaches, which can reduce academic performance and quality of life. - **Preventive measures:** School educational programs to correct posture, increase awareness of the correct body position and adjust the weight of the backpack can reduce the prevalence of these pains. ### **Neck and shoulder pain in adults** - **Base rate and geographic variation:** Demographic studies have shown that the six-month prevalence of neck pain in adults is **6.9-54.2%** and the global average is around **29.8%**. - **Occupational and lifestyle factors:** People who sit for long hours at a desk or do repetitive tasks with their hands, have up to **55%** probability of neck pain; The improper position of the monitor and the use of the mobile phone with the head bent increases the pressure load. - **Biological and psychological factors:** Low income, low education, several simultaneous diseases and depression are among the most important factors associated with neck pain. There is also a significant relationship between high BMI and shoulder pain symptoms. - **Pattern of shoulder pain:** Prevalence of shoulder pain in adults is usually lower than neck pain, but with increasing age and physical workload, it has been reported up to **50%**. - **Physiotherapy role:** Movement training programs, posture correction and manual therapy can reduce up to **70-80%** of pain symptoms and accelerate the return to activity. ### **Neck and shoulder pain in the elderly** - **Prevalence based on age:** In the age group of 70-79 years, **11.9%** of people reported neck pain for one month and **18.9%** shoulder pain. - **Increase after age 50:** Most studies show that the prevalence of shoulder pain increases steadily after age 50; This has been seen in jobs with more physical load, up to **60%**. - **Background factors:** Arthritis, muscular dystrophy, diabetes, smoking and cardiovascular complications are related to the severity of shoulder and neck pain in the elderly. - **Other reasons:** Reduction of muscle mass (sarcopenia), reduction of flexibility of connective tissue and reduction of inflammatory reaction cause chronic pain. - **Rehabilitation strategies:** In the elderly, short and mild exercises focusing on balance, flexibility and mild strengthening (exercises with body weight) and mild manual therapy are most effective. Using heat and cold modalities is also useful to reduce inflammation. Neck and shoulder pain in certain jobs In different occupational environments, the prevalence of neck and shoulder pain is significantly different, and up to 63% have been reported in office workers, health organizations, and handicrafts. Manual workers and drivers are also at high risk of musculoskeletal complications due to mechanical load and long-term static position. Developing ergonomic programs and implementing active breaks can reduce pain symptoms by 70-80% and prevent chronic complications. - **Office Workers** The annual prevalence of neck pain in office workers has been reported to be between 42-63%, which is one of the highest rates among known occupations. In a cohort study in Europe, 54.9% of computer operators experienced neck or shoulder pain in the past 12 months, and 34.3% of them still had symptoms one year later. Annually, 31.8 new cases of musculoskeletal disorders per 10,000 person-years have been reported in jobs with light manual work such as clerical work. - **Manual Labor Workers** In jobs such as construction and factories, heavy loading and repetitive movements lead to a high prevalence of tendinopathy and chronic neck and shoulder pain. Workers in this field experience up to 60% of musculoskeletal disorders. - **Drivers and other service occupations (Drivers & Service Occupations)** Drivers of heavy vehicles report a 40-50% prevalence of neck and shoulder pain due to the fixed position of the neck and constant vibration of the cabin. 86% of hospital staff have experienced muscle pain in the neck and shoulder area. Preventive interventions and improving the implementation of personalized ergonomic programs including posture training, equipment adjustment and monitoring the continuity of active breaks can reduce 70-80% of pain symptoms. The use of intermittent stretching beds and self-care training such as simple massages and daily stretching exercises play an effective role in preventing pain from becoming chronic. **Conclusion** The prevalence and intensity of neck and shoulder pain changes with age and changes in physiological and environmental conditions. In adolescents, rapid growth and sports activities can cause a high prevalence; In adults, lifestyle and work environment play a key role, and in the elderly, structural changes in joints and muscles cause chronic pain. Knowing these age patterns helps physiotherapists to develop appropriate treatment and preventive programs for each group and prevent the recurrence of pain. Sources: • Physio-Pedia: Office Ergonomics and Neck Pain • PMC: Persistent Neck/Shoulder Pain in Computer Operators • BMC Public Health: Sedentary Behavior and Neck Pain Risk • PMC: Neck Pain Prevalence in Office Workers • Verywell Health: Work-Related Musculoskeletal Disorders • Nature: Prevalence of Neck/Shoulder Pain among Hospital Workers • Sci. Direct: Neck Pain Prevalence and Occupational Factors • OUP: Workplace-Based Interventions for Neck Pain • SAGE Journals: Musculoskeletal Pain in Office vs. Other Workers • Wikipedia: MSD Epidemiology Workplace Data